Healthcare Provider Details

I. General information

NPI: 1275851040
Provider Name (Legal Business Name): BREANNE J NOWAKOWSKI PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BREANNE J SERGENT PA

II. Dates (important events)

Enumeration Date: 05/04/2010
Last Update Date: 05/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5005 N PIEDRAS ST
EL PASO TX
79920-5001
US

IV. Provider business mailing address

2435 MCKINLEY AVE VILLA SIERRA #73
EL PASO TX
79930-2238
US

V. Phone/Fax

Practice location:
  • Phone: 915-569-2131
  • Fax: 915-569-2107
Mailing address:
  • Phone: 631-942-7860
  • Fax: 915-569-1233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number013701-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: